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        <p>玻璃基陶瓷嵌体粘接流程模式二（适合多颗嵌体粘接）<br>第一步：模型上检查嵌体密合度及边缘<br>第二步：检查嵌体组织面隐裂及气泡及釉液涂过边缘（有的话要去除，加工单上应特别标注）的情况。<br>第三步：清洁玻璃基陶瓷嵌体。<br>第四步：9.5%HF酸蚀组织面，Emax20s，白榴石基60s。<br>第五步：酸蚀满足时间冲洗1min。<br>第六步：水雾清洁干净超声荡洗2-5min取出干燥。<br>第七步：涂布硅烷偶联剂1-2层放置通风处隔日预约患者试戴<br>第八步：取掉口内临时修复体清洁预备体<br>第九步：试戴嵌体<br>第十步：超声荡洗2min去掉污染（硅烷与硅烷的连接，而硅烷与瓷的连接不能去除）<br>第十一步：涂布瓷粘接剂（厚度&lt;2mm）不固化<br>第十二步：嵌体厚度大于3mm时可不涂任何粘接剂。<br>第十三步：IDS区域或重建区域上障喷砂<br>第十四步：釉质区35%磷酸酸蚀30s(IDS区可酸蚀清洁15s），强吸吸净水雾冲洗15s，彻底干燥，涂布粘接剂。涂抹20s后温柔而彻底干燥10s表面发亮，光固化10s。<br>2.玻璃基陶瓷贴面粘接流程<br>多颗贴面的粘接<br>第一步：模型送回后，检查边缘密合度及邻接点及组织面。<br>第二步：清洁贴面组织面干燥。<br>第三步：9.5%HF酸处理组织面。<br>Emax 20s<br>白榴石陶瓷贴面60s<br>长石质贴面（烤瓷贴面）90s<br>第四步：冲洗1min<br>第五步：水雾冲洗干燥<br>第六步：95%乙醇或丙酮中超声振荡2-5min<br>第七步：超声振荡后干燥<br>第八步：涂布硅烷偶联剂1-2层，预约患者<br>第九步：取掉临时充填物清洁预备体表面试戴。（粘临时贴面的点状树脂区域用刀刮掉。放开口器，可以不上障。）<br>第十步：95%乙醇或丙酮超声荡洗试戴后的贴面。<br>第十一步：涂布一薄层瓷粘接剂吹匀发亮无波动不固化。<br>第十二步：如预备体制备完全在釉质层浮石清洁后32%磷酸酸蚀30s。如预备体表面有树脂喷砂清洁后32%磷酸酸蚀釉质30s。<br>第十三步：强吸吸走磷酸水雾冲洗15s无油空气干燥。<br>第十四步：预备体表面涂布All-Bond 3(A+B)<br>滴入器皿混合A、B液5s，涂布表面10-15s，再次涂布表面10-15s，吹10s至表面发亮，固化20s（也可不固化）。<br>第十五步：修复体组织面涂布光固化水门汀就位清除多余水门汀固化。<br>第五阶段：术后敏感的控制<br>第一节：敏感产生的关键点<br>1）存在暴露的牙本质表面<br>2）暴露的牙本质表面存在开放的牙本质小管口<br>3）这些开放的小管通向牙髓。<br>第二节：产生敏感的原因及应对措施<br>敏感原因分析：<br>①未完全去除酸蚀剂<br>酸可以清除自由基影响聚合。<br>解决方案：使用半凝胶磷酸；冲洗时间够，建议15s；注意线角处。<br>②涂布全酸蚀粘接剂前，牙齿表面湿度不当（太湿、太干或完全脱水）。<br>解决方案：了解底漆或底漆/粘接剂的溶剂类型；使用大容量的窝洞负压吸引器；使用专用吸湿棉球。<br>③涂布全酸蚀粘接剂前，牙齿表面湿度不当（太湿、太干或完全脱水）。<br>解决方案：了解自酸蚀粘接系统的溶剂/水比例;All Bond Universal自酸使用时牙本质湿润；All Bond SE使用时牙本质干燥。<br>④底漆及粘接剂涂布不当<br>解决方案：<br>a.底漆涂布微用力创造纤维间通道和促进溶剂挥发。<br>b.底漆涂布是溶剂挥发易变稠影响渗入，建议多层涂布，因为可以有持续新鲜的溶剂及单体使混合层形成更好。<br>c.全酸底漆含水量较少轻柔的吹10s发亮不动即可。<br>d.粘接剂涂布时溶剂挥发易变稠影响渗入，建议多层涂布因为可以有持续新鲜的溶剂及单体使混合层形成更好。<br>⑤粘接过程中的污染（血液、唾液或气吹中的油液/水）。<br>酸蚀后污染：重新酸蚀。<br>涂全酸底漆固化前污染：重新酸蚀后涂底漆。<br>涂自酸底漆后污染：清洗后重新涂布。<br>涂布粘接剂固化前污染：重新酸蚀涂底漆；重新涂布粘接剂。<br>涂布粘接剂固化后污染：乙醇清洁表面；干燥表面继续操作。（因为是疏水界面）<br>预防：使用橡皮障。<br>⑥使用过期的牙本质粘接剂<br>观察保质期；不使用瓶口边缘的粘接剂。<br>⑦树脂饱和度不足或未充分渗入暴露的胶原和牙本质小管（牙本质小管未封闭）<br>遵守操作流程。<br>⑧牙本质粘接剂过薄，受空气抑制影响，聚合不足。<br>粘接剂成膜不可过薄。<br>⑨粘接剂未充分吹干（常见于水或乙醇为溶剂的粘接剂）<br>遵守操作流程<br>⑩光固化不充分，特别是固化灯头离粘接剂表面距离太远<br>探头距离粘接界面3mm以内<br>⑪光固化灯不符合粘接剂要求的光谱<br>了解树脂引发体系。<br>⑫复合树脂收缩会在牙本质底层形成裂纹或使釉质边缘开裂。(不需要高光强的固化灯）<br>a.分层堆塑<br>b.胡克定律及C因素<br>第三节：术后敏感的诊断和应对措施<br>1.大面积一类或二类洞型术后咬合痛冷热不痛<br>原因分析：髓壁脱粘接小管液渗出合力传导<br>解决方案：<br>a.约诊检查咬合有无高点<br>b.拍摄X光片有无穿髓角区<br>c.无自发痛表现时观察4-6周<br>d.观察4-6周减轻消失不做处理。<br>e.观察4-6周未减轻彻底去除后自酸蚀修复。<br>2.二类洞及五类洞术后咬合无痛冷热酸甜刺激痛。<br>原因分析：边缘封闭不良，可以用饱和氯化钙溶液置于边缘10-15s辅助诊断。<br>解决方案：<br>a.约诊上障暴露边缘<br>b.35%磷酸重新酸蚀釉质边缘30s干燥<br>c.涂布BISCOVER或ENA-Seal 20s<br>d.固化10s阻氧剂再固化20s<br>e.未见好转磨开边缘喷砂酸蚀粘接充填<br>第四节：预防敏感的原理<br>根据液体流动理论提出两个基本解决方法：<br>A.阻塞开放的牙本质小管以减少液体流动引起的刺激<br>三个基本方法：<br>1.草酸钙沉积<br>BisBlock草酸钾脱敏剂（适应症：封闭活髓深部牙本质需要全酸蚀）<br>现在少用，材料买不到。<br>2.血浆蛋白沉积<br>Gluma底漆 原理：生物固定技术组织人血红蛋白流动。<br>现在也不用了。<br>3.使用自酸蚀粘接模式(适合中深龋）<br>用第六代粘接剂。<br>第五节 即刻封闭牙本质小管IDS<br>1.优点<br>a.可防止细菌和残余暂时粘接材料的侵入<br>b.取模前，通过预固化牙本质粘接剂建立具有相当厚度的混合层可以减少取模和粘固中的胶原纤维塌陷。<br>c.在无水门汀聚合收缩应力应变的条件下建立混合层可帮助形成无应力牙本质粘接。<br>d.有效封闭牙体本质可解决牙本质小管内液体流动的问题，有研究表明这种小管内液体流动会引起牙齿敏感。<br>e.减少临时冠和正式冠术后牙齿的敏感，让患者满意。<br>f.IDS不会影响粘接强度，而且能帮助间接修复体获得最理想的牙本质粘接强度<br>g.IDS的时机：预备后印模前。<br>2.全冠预备后IDS流程<br>①备牙后，2%洗必泰清洁预备牙体30s<br>②All-Bond Universal涂布10-15s，再重复一遍（从底部向冠方涂）<br>③气流由弱到强吹10s表面发亮<br>④固化10s<br>⑤涂布All Bond 3 Resin一层固化内外各10s（流体可替代）<br>⑥涂布阻氧剂后固化内外各20s<br>⑦冲洗阻氧剂酒精擦拭表层精修暴露肩台釉质边缘。<br>⑧印模<br>3.嵌体预备后的IDS流程（嵌体中大窝洞使用，操作熟练，易引起术后疼痛）<br>①备牙后清洁预备体32%磷酸酸蚀10-15s<br>②彻底冲洗强吸吸去表面多余水分保持牙本质湿润<br>③涂布All Bond 3(A+B)10-15s，再重复一遍<br>④气流由弱到强温柔而彻底的干燥表面无材料流动<br>⑤500mW/cm²内外各照10s<br>⑥无缺损的洞型涂布All Bond Resin一薄层过釉牙本质界1mm固化20s<br>⑦有缺损的树脂重建至标准固化2s，涂布阻氧剂后固化30s<br>⑧冲洗阻氧剂后酒精擦拭30μm车针精修釉质表面粘接剂暴露釉质。<br>⑨印模或扫描。<br>嵌体预备后IDS流程（改良式）<br>①备牙后，2%洗必泰清洁预备牙体30s<br>②All-Bond Universal涂布10-15s重复一遍，过釉牙本质界1mm。<br>③气流由弱到强吹10s表面发亮<br>④固化10s<br>⑤涂布All Bond 3 Resin一层过釉牙本质界固化10s（有缺损树脂充填）<br>⑥涂布阻氧剂后固化20s<br>⑦冲洗阻氧剂酒精擦拭表层30μm车针精修釉质表面粘接剂暴露釉质。<br>⑧印模。<br>4.根面脱敏的标准流程<br>没有缺损的根面暴露<br>步骤<br>①32%-37%磷酸酸蚀10-15s，冲洗，吹干3-5s<br>②涂布草酸盐溶液，等待30s，冲洗，保持牙本质潮湿<br>③涂All Bond 3(A+B)20-30s固化后涂All-Bond 3 Resin固化。<br>④涂布一层无氧气抑制层的树脂（BISCOVER）（可选）<br>⑤吹气，检查脱敏效果。<br>现在很少用，使用冠向复位瓣技术解决。</p>
<p>个人总结：多颗嵌体粘接过程：预先HF、硅烷偶联剂处理，隔日约患者复诊，试戴嵌体，超声荡洗清洁，涂布瓷粘接剂（厚度&lt;2mm）不用固化，上障处理牙面，涂布粘接剂，光固化，用粘固水门汀粘固。<br>贴面类似，用到刮掉粘临时贴面的点状树脂。使用光固化水门汀。<br>术后粘接的控制：敏感产生的关键点：①暴露的牙本质表面；②暴露的牙本质表面有开放的牙本质小管口；③开放的小管通向牙髓。敏感原因：未完全去除酸蚀剂、涂布粘接剂前，牙齿表面湿度不当；底漆及粘接剂涂布不当；粘接过程中的污染；使用过期的牙本质粘接剂（包括使用瓶口的粘接剂）；树脂饱和度不足或未充分渗入暴露的胶原和牙本质小管；牙本质粘接剂过薄，受空气抑制，聚合不足；粘接剂未充分吹干；光固化不充分，光固化灯头离粘接剂表面距离太远；光固化灯不符合粘接剂要求的光谱；复合树脂收缩会在牙本质底层形成裂纹或使釉质边缘开裂。应对措施：咬合痛，冷热不痛：内封闭出问题，观察，返工自酸蚀重新修复。咬合不痛，冷热酸甜刺激痛：外封闭出问题，暴露边缘，重新处理，粘接充填（里面不动）。封闭牙本质小管，现在常用自酸蚀粘接模式。IDS主要作用是封闭牙本质小管，解决敏感和细菌、材料侵入的问题。流程同充填粘接，但是要用含树脂填料的粘接剂或单独使用树脂，以形成足够的厚度抵抗喷砂。根面脱敏现在已少用，使用冠向复位瓣技术解决。(粘接课程完成，改天写个总结吧。)</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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